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Debt and the Emerging Physician Workforce

The Relationship Between Educational Debt and Family Medicine Residents’ Practice and Fellowship Intentions

Phillips, Julie P., MD, MPH; Peterson, Lars E., MD, PhD; Fang, Bo, PhD; Kovar-Gough, Iris, MA, MLIS; Phillips, Robert L. Jr, MD, MSPH

doi: 10.1097/ACM.0000000000002468
Research Reports

Purpose Educational debt is increasing and may affect physicians’ career choices. High debt may influence family medicine residents’ initial practice setting and fellowship training decisions, adversely affecting the distribution of primary care physicians. The purpose of this study was to determine whether debt was associated with graduating family medicine residents’ practice and fellowship intentions.

Method The authors completed a cross-sectional secondary analysis of 2014 and 2015 American Board of Family Medicine (ABFM) examination registration questionnaire data and ABFM administrative data. They used multivariate logistic regression to determine whether educational debt was associated with graduating residents’ practice (ownership and type) and fellowship intentions.

Results Most residents (89.7%; 3,368) intended to pursue an employed position, but this intention was not associated with their debt. Residents with high debt ($150,000–$249,999) had lower odds of intending to work for a government organization (odds ratio [OR] 0.57; confidence interval [CI] 0.41–0.79). Those with high or very high debt (> $250,000) had lower odds of choosing academic practice (OR 0.55, CI 0.36–0.85 and OR 0.62, CI 0.40–0.96, respectively) or a geriatrics fellowship (OR 0.36, CI 0.20–0.67 and OR 0.29, CI 0.15–0.55, respectively).

Conclusions High educational debt may contribute to national shortages of academic primary care physicians and geriatricians. Existing National Health Service Corps loan repayment opportunities may not offer adequate incentives to primary care physicians with high debt. The medical community should advocate for policies that better align financial incentives with workforce needs.

J.P. Phillips is assistant dean, Student Career and Professional Development, Michigan State University, and associate professor, Sparrow-MSU Family Medicine Residency Program, Lansing, Michigan; ORCID:

L.E. Peterson is research director, American Board of Family Medicine, Lexington, Kentucky; ORCID:

B. Fang is research assistant, American Board of Family Medicine, Lexington, Kentucky.

I. Kovar-Gough is liaison librarian to the College of Human Medicine, Michigan State University Libraries, East Lansing, Michigan; ORCID:

R.L. Phillips Jr is vice president for research and policy, American Board of Family Medicine, Lexington, Kentucky.

Funding/Support: Julie Phillips’ work was supported by the American Board of Family Medicine Foundation.

Other disclosures: None reported.

Ethical approval: The American Academy of Family Physicians institutional review board approved this study (protocol no. 14-203, approved on April 28, 2014).

Disclaimer: The study findings and their interpretation are the authors’ own, and they do not reflect the views of the American Board of Family Medicine or the American Board of Family Medicine Foundation.

Previous presentations: The results of this study were presented at the Society of Teachers of Family Medicine annual spring conference, San Diego, California, May 8, 2017; and at the North American Primary Care Research Group annual meeting, Montreal, Quebec, Canada, November 21, 2017.

Correspondence should be addressed to Julie P. Phillips, Sparrow-MSU Family Medicine Residency Program, 1215 Michigan Ave., Suite 245, Lansing, MI; telephone: (616) 234-2672; e-mail:; Twitter: @juliephillips07.

© 2019 by the Association of American Medical Colleges